PHYSICIANS have not always enjoyed the exalted place in our culture they do today. Until the late 19th century, they lived an existence so marginal that-- according to Paul Starr in his new history, The Social Transformation of American Medicine, a doctor was advised to keep a farm so he would not be tempted in his financial desperation to cherish, "even for a moment, an impious wish for the prevalence of sickness in your neighborhood." And one doctor, "not satisfied with his practice, robbed stagecoaches on the side," a kind of moonlighting that Starr suggests may have been a result of his search for thrills as much as of his need for solvency.
The Social Transformation of American Medicine meticulously traces how medicine changed from a financially precarious, and disorganized profession with very little status to a respected, lucrative, and organized one. And how it is in the process of changing again-- through the development of medical corporations, which will be able to hire or fire doctors depending on how healthy their bottom-lines, rather than patients, are.
This coming revolution is simply one more version of a conflict that has been played and replayed throughout the history of American medicine, a battle over power. Who has the power in medicine? The patients? The doctors? The State? The medical schools? Medical societies? Insurance companies?
This conflict can be as simple or as complex as a definition of what medicine is. A humanitarian obligation? A trade? A commodity?
Sometimes the conflict appears in the guise of a battle between the free market place and professional standards. Or between quackery and science. Or between patients' self-reliance and professional intervention. Or between intellectual populism and intellectual elitism. Or competition and monopoly. The conflict changes its nature as the social and economic context changes.
In pre-industrial America, when people lived primarily on farms that were far from towns and villages, they tended to take care of themselves. As the country became more populated and the farms were not so isolated, people began to use with increasing frequency itinerant lay doctors--generalists like botanics and white or mulatto "Indian doctors" or specialists like midwives, inoculators, and bone-setters. With the rise of industrialism and the growth of cities, people began more and more to turn to professionally trained doctors; health became a product one bought. Or that was the illusion.
It is not surprising that such a product--one on which 10 percent of the country's gross national product is spent annually--would attract for-profit corporations and that those corporations would try to undercut the competition, the independent entrepreneurs, the doctors, who soon may find themselves no longer relatively autonomous professionals but simply cogs in the Medical-Industrial Complex, wage-slaves as much as workers on an assembly line and just as subject to the needs of the companies for which they work.
As in the Military-Industrial Complex, science will become subservient to technology, which will become subservient to profits, which will be generated by political decisions, which will be influenced by corporate demands, which will rise out of a need to control the market. Health will become merely a byproduct.
Those who are too poor or too disenfranchised to fit profitably into the system may tend to rely on lay doctors or home-remedies as the poor did in the past. Already in some cities, botanicas can be found in neighborhoods inhabited by the poor, particularly by recent immigrants who feel uncomfortable in hospitals or clinics and who in some cases are not welcome there.
The high cost of medical care and the growing depersonalization of some hospitals, making them seem like health factories, may lead more and more of the educated middle-class away from the medical system, too. Although since the late 1960s and early '70s, counterculture health care--homeopathy, home-births, mystical medicine--has lost much of its allure, there has been an increase in general public acceptance of nutrition, preventive medicine, hospital-based midwifery, and behavioral medicine. The trend toward health-care centralization in ever-larger hospital and medical school complexes may be met by a countertrend toward small independent community clinics, hospices, home care, and the use of paraprofessionals.
The Social Transformation of American Medicine raises and examines such questions with authority, facility, and an intellectual passion uncompromised by emotionalism. Although Starr apparently distrusts the trend toward medical corporations, he presents his material fairly and conscientiously supports his conclusions with lucid arguments and an elegant use of his research.
Throughout the book, he keeps the main line of his thought clear without sacrificing detail or complexity. Although The Social Transformation of American Medicine may be a little too specialized to have a large popular audience, it is thorougly accessible to anyone-- even someone innocent of medical history or of the issues currently surrounding the profession.
The book is intermittently marred by alternating Olympian archness and slack recital of facts, the hills and valleys of academic prose, but in general Starr offers a language informed by common sense. He is informative rather than entertaining, reasonable rather than provocative, serviceable rather than dazzling. His voice betrays Masterpiece Theatre Syndrome (also known as the Alistair Cooke Complaint), a tendency to appeal to an audience's self-regard, its earnest belief in its own superiority--as proved by its desire to improve itself painlessly by watching television versions of classics it might not have the time or inclination to read. This knowing nudge-in-the-ribs clubbiness is sounded in the very first line of the acknowledgments.
"This book was written in the old-fashioned way: the lone scholar pecking away at his word processor."
But this stylistic quibble reflects only on how good the book otherwise is. Had Starr found a voice equal to his scholarship and moral seriousness, he would have written a book that was a work of art as well as superb history and sociology.
As it is, Starr has written what will probably remain for many years to come the definitive work on American medicine.